Utilization Review Nurse – LTSS (Contract-to-Perm) - REMOTE

This is your chance to join one of the nation’s most respected Managed Care Organizations, known for its commitment to delivering high-quality, cost-effective healthcare to underserved populations. With a culture of compassion and innovation, this organization is recognized for prioritizing patient outcomes and creating opportunities for professional growth across the country.

Utilization Review Nurse – LTSS (Contract-to-Perm) Location: Remote however Candidates must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY, OH, TX, UT, WA, or WI Schedule: Monday–Friday | 8:00 AM – 4:30 or 5:00 PM EST Pay Rate: $42.00 per hour + Full Health Benefit Plan Offered Contract-to-Hire Opportunity Position Overview The Utilization Review Nurse (LTSS) supports the Utilization Management team and is responsible for reviewing long-term services and supports (LTSS) provider requests, primarily by evaluating clinical documentation to ensure appropriateness of care, cost efficiency, and compliance with state and federal regulations. The role plays a critical part in ensuring members receive the right care at the right time, particularly under Virginia Medicaid guidelines.

Review LTSS provider service requests against case management documentation Conduct prior authorization and concurrent reviews in accordance with clinical guidelines and organizational policy Complete reviews within turnaround time (TAT) expectations Identify member eligibility, applicable benefits, and appropriate levels of care Collaborate with internal care teams, including Behavioral Health and Long-Term Care Refer cases to medical directors when needed for clinical decision-making Participate in staff meetings and cross-functional collaboration Provide mentorship to new team members as assigned Maintain documentation standards, compliance, and productivity benchmarks Ensure HIPAA and regulatory compliance at all times